Wednesday 11 June 2008

By Dr Nicholas Tonti Filippini

The Medical Treatment (Physician Assisted Dying) Bill 2008 provides that a doctor may prescribe a drug to a patient with a terminal or advanced incurable illness so that person may swallow it and die. Some matters to consider about the Bill are:

• The Bill has a very wide scope, it affects not just those who are dying, but also those who have an advanced chronic illness. 
• The Bill has been proposed and apparently drafted by Mr. Neil Francis, the President of Dying with Dignity Victoria, and has not originated from any broad-based enquiry that could take into account the interest of all Victorians and especially those with chronic or terminal illness.
• The Bill would expect the doctors involved to prescribe a drug not for the care of the patient or the treatment of illness, but to intentionally and actively intervene to end the life of the patient. In that respect, the Bill is not supported by the Australian Medical Association or any of the medical Colleges. The AMA’s policy on euthanasia is to “strongly oppose any bill to legalize physician-assisted suicide or euthanasia, as these practices are fundamentally inconsistent with the physician’s role as healer”(1).
• The Bill has not been supported by organizations and institutions directly involved in aged care, the care of the dying or the care of those with chronic illness. In fact such a law would provide a political out for the obligation of governments to provide long term funding of care and support for people with advanced chronic illness including aged care and palliative care.
• The Bill would not benefit Victorians who suffer from chronic illnesses. Instead it would make protection of their lives dependant on the strength of their will to continue. The fear of being a burden is a major risk to the survival of those who are chronically ill. If euthanasia were lawful, that sense of burden would be greatly increased for there would be even greater moral pressure to relinquish one’s hold on a burdensome life.
• The Bill is based on claims about existential pain. Pain of an existential nature arises usually from loneliness and a lack of sense of self worth. Providing the option of euthanasia provides an out for families and carers and the fact that the option exists would be likely to make someone who had a burdensome illness feel even less valued and increase the likelihood that they would choose death over dying alone or being a burden to others. Serious illness and dying are times when a person needs the support of others so that others can share empathy with that person(2). The possibility of opting instead for a fatal prescription would cast a shadow over those relationships in which the person feels wanted and valued.
• Pain and suffering are complex involving physical, psychological, emotional and spiritual elements. Palliative care seeks to address the needs of those who are suffering in a multi-disciplinary way that reflects the many elements involved (3). Crucial to good palliative care is the support of the patients socially, emotionally and spiritually. It is not simply a matter of relieving physical pain. For those who continue to live with a burdensome illness, the option of euthanasia would undermine one of the essential elements of good pain relief, the notion that the person is supported, loved and wanted.
• In other places, such as the United Kingdom, for instance, which have adopted very liberal policies on other social policies, such as reproductive technology, gay unions and abortion, have strongly opposed euthanasia because euthanasia cannot be made safe for people who are seriously ill and thus vulnerable.
• Euthanasia law cannot be made safe. The Northern Territory briefly had similar law. Several of those for whom the legislation was implemented did not in fact meet the criteria of the Bill despite the safeguards(4). This is reflected also in the Dutch experience where much larger numbers than were expected have been subject to the law raising human rights concerns, see United Nations concern below.
• Euthanasia is contrary to the International Human rights instruments. When the Human Rights Committee of the United Nations considered a euthanasia law enacted in the Netherlands to codify what had become euthanasia practice, the Committee said that where a State party seeks to relax legal protection with respect to an act deliberately intended to put an end to human life, the Committee believes that the International Covenant on Civil and Political Rights obliges it to apply the most rigorous scrutiny to determine whether the State party's obligations to ensure the right to life are being complied with (articles 2 and 6 of the Covenant). The Committee expressed the concerns that the new Act contains a number of conditions under which the physician is not punishable when he or she terminates the life of a person, inter alia at the "voluntary and well-considered request" of the patient in a situation of "unbearable suffering" offering "no prospect of improvement" and "no other reasonable solution". The Committee also expressed concern lest such a system may fail to detect and prevent situations where undue pressure could lead to these criteria being circumvented. The Committee was also concerned that, with the passage of time, such a practice may lead to routinization and insensitivity to the strict application of the requirements in a way not anticipated. The Committee learnt with unease that under the present legal system more than 2,000 cases of euthanasia and assisted suicide (or a combination of both) were reported to the review committee in the year 2000 and that the review committee came to a negative assessment only in three cases. The large numbers involved raise doubts whether the present system is only being used in extreme cases in which all the substantive conditions are scrupulously maintained (5).

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Dr Nicholas Tonti Filippini is an Associate Professor at the John Paul II Institute for Marriage and Family, Melbourne. He is the Institute Associate Dean (Teaching, Learning and Research),  Head of Bioethics and is also a consultant in bioethics. He is a member of the Australian Health Ethics Committee of the National Health and Medical Research Council and chair of the sub-committees on the Unresponsive State and Comercialisation of Human Tissue.

(1) http://www.ama-assn.org/apps/pf_new/pf_online, accessed 15/5/08
(2) Yvonne Yi Wood Mak and Glyn Elwyn “Voices of the terminally ill: uncovering the meaning of desire for euthanasia” Palliative Medicine, Vol. 19, No. 4, 343-350 (2005)
(3) Hudson Peter, Kristjanson Linda J, Ashby Michael , Kelly Brian, Schofield Penelope, Hudson Rosalie, Aranda Sanchia,, O’Connor Margaret, Street Annette.(2006) A systematic review of the desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines Palliative Medicine 20, 693-71
(4) David W Kissane, Annette Street, Philip Nitschke, ‘Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia,’ The Lancet, 1998 Vol 352: 1097-1102
(5) http://www.unhchr.ch/tbs/doc.nsf/0/dbab71d01e02db11c1256a950041d732?OpenDocument&Highlight=0,euthanasia , accessed 26/5/08